Radiology (Position Paper)

See also

Family Physician Interpretation of Outpatient Radiographs

Overview and Justification

Most family physicians provide the majority of their patient care in the outpatient setting. Diagnostic radiography is an integral part of the evaluation and management of acute and chronic illnesses for patients seen in the office and a part of the patient-centered medical home (PCMH). Practices that have radiology services on-site usually do not have a radiologist on staff, so the family physician orders and interprets the radiographs and renders patient care based on the initial interpretation. This is often the case in the rural setting and offers a valuable service to the patients, allowing care at a local level and providing necessary services for those who would have difficulty traveling to another location to obtain services. As a result, the family physician integrates the patient’s history, physical examination, laboratory testing, and his or her interpretation of diagnostic radiographs to develop a working diagnosis and treatment plan. The radiograph is often reread by a radiologist, and care may be modified if there is a clinically significant discrepancy between the readings, with only occasional changes to those plans after the radiologist’s rereading.

The family physician provides a necessary service when offering radiography, and receives the necessary training in residency to interpret radiographs. The radiologic services provided and the tests to be over-read are at the discretion of the individual practices. Providing x-ray services in the family medicine office saves the health care system money, since the patient is seen in the office and not in the emergency department (ED) or urgent care center. This also reduces transitions of care and allows the patient to remain in the PCMH for splinting or definitive care of fractures or sprains. In the PCMH model, the family physician has access to the complete history and his or her own exam, which aids in interpretation of the radiography. Finally, this reduces fragmentation of care that can occur when an urgent care or ED doctor refers the patient out of the PCMH to another specialist after performing the radiography. Radiography services are an important part of a family physician’s diagnostic armamentarium and aid in the appropriate care of our patients.

National Healthcare Expenditure (NHE) grew 4.0 percent to $2.5 trillion in 2009, or $8,086 per person, and accounted for 17.6 percent of gross domestic product (GDP). Medicare spending grew 7.9 percent to $502.3 billion in 2009, or 20 percent of total NHE. Medicaid spending grew 9.0 percent to $373.9 billion in 2009, or 15 percent of total NHE. Private health insurance spending grew 1.3 percent to $801.2 billion in 2009, or 32 percent of total NHE. Out of pocket spending grew 0.4 percent to $299.3 billion in 2009, or 12 percent of total NHE. Physician and clinical services expenditures grew 4.0 percent in 2009, slower than the 5.2 percent in 2008. The federal government share of health care spending increased just over 3 percentage points in 2009 to 27 percent, while the shares of spending by households (28 percent), private businesses (21 percent), and state and local government (16 percent) fell by about 1 percentage point each.1

“[The number of] imaging studies paid for under Medicare’s physician fee schedule grew more rapidly than any other type of physician service between 2000 and 2005. Some evidence suggests that Medicare may be overpaying for certain costly imaging services, which could be contributing to rapid volume growth.”2 “Although the sum of all physician services grew 31 percent between 2000 and 2005, imaging services paid for under the physician fee schedule grew twice as fast, by 61 percent (10 percent per year, on average). Growth in imaging services slowed between 2005 and 2006, to 6.2 percent, but it remained much higher than growth in total physician services (3.6 percent). These numbers measure growth in the volume and intensity of services per beneficiary; they control for increases in the number of beneficiaries and changes in prices during those years. These figures also exclude imaging studies performed in hospital outpatient departments.”2

According to the American Academy of Family Physicians (AAFP) 2009 Practice Profile Survey based upon 2008 data, 46.3 percent of AAFP members surveyed offer x-ray services in their practices (up from 45.2 percent in the previous year), 17.5 offer obstetric ultrasound (15.9 percent in previous year), 14.8 offer non-OB ultrasound, and 13.7 percent offer echocardiography (up from 8 percent in 2005 and 12 percent in 2008).3 No recent data specifically about office radiology use have been published. Sunshine estimated that in 1989, 1.8 percent of total radiology work was performed by family physicians and general practitioners.4 According to an American College of Radiology (ACR) PowerPoint presentation, “In recent years, we have seen an exponential rise in imaging performed by other medical specialties and efforts by government and private payers to cut reimbursement for imaging services. From 1998 to 2005, the nonradiologists’ share of in-office MRI and CT doubled and tripled, respectively. Nonradiologists received more than double the amount of Medicare dollars paid to radiologists for in-office imaging during that span — nearly $4 billion. The result is that nearly three-quarters of all nonhospital imaging is now performed by nonradiologist providers.”5

Thirty-one percent of respondents indicated being denied payment for an office procedure within the past 12 months. The percentage in 2009 is significantly higher than the 10 percent of respondents experiencing denial of payment in 2006. Reasons given by respondents for not performing x-rays in their office practice are primarily expense of equipment and lack of desire. The percentage of respondents indicating that training is an issue in offering x-rays in their office has declined significantly from 8.1 percent in 2005 to 2.3 percent in 2009. The percentage of respondents indicating a lack of desire to provide echocardiography has decreased significantly from 70 percent in 2008 to 53 percent in 2009. An increase in the incidence of respondents reporting lack of training as a reason for not providing echocardiography was observed; the percent increased from 16 percent in 2008 to 22 percent in 2009.3

Physicians billing for office radiography may bill for the technical component (taking the pictures) or the professional component (reading the images) or both. A family physician with on-site radiography equipment will typically bill for the technical component of the imaging service. If the family physician also reads the radiographs and generates a separate written report, then the professional component would be billed also. If the radiographs are initially read by the family physician and over-read by a radiologist who generates the written report, the radiologist bills for the professional component.

The Congressional Budget Office (CBO) has observed that technological advances are likely to yield new, desirable medical services in the future that, while improving care, will increase costs. Technology-related changes in radiology and other areas have contributed 38 to 62 percent of the increase in health care costs from 1940 to 1990, and the percentage is expected to grow.6 The PCMH promotes increasing patient access and same-day services. By offering radiology services in the practice, it reduces access issues and decreases the time to diagnosis and treatment.7 However, there are strict rules governing physician self-referring that can hinder the ability to offer services.8

Concern has been expressed that on-site radiography leads to more frequent use and results in increased health care costs.9-13 However, one study reported that a decision by an insurer to deny claims for professional charges for radiologic services performed by nonradiologists resulted in a 12 percent increase in expenditures.14 Another study of general practitioners in New Zealand reported an increase in ED referrals and hospital admissions in areas of decreased patient access to imaging services.15 More factors than simply having on-site radiography equipment may influence the frequency of use. Wilson reported a comparison of primary care physicians with and without on-site radiography and found an increased frequency of chest x-rays among physicians with on-site radiography, but an equal frequency of lumbar spine x-rays.16 It is clear that on-site radiography influences the frequency of imaging procedures. However, neither the appropriate frequency of radiography use nor what negative effect increasing distance to imaging facilities has on appropriate use is known. Because of its importance in initiating immediate therapy, office radiology is a significant part of the practice of many family physicians. The number of radiologic services they provide is relatively small compared with the total, and the exact costs of plain film radiography attributable to family physicians is not known.

Section I: Scope of Practice for Family Physicians

It is the position of the AAFP that clinical privileges should be based on each individual physician’s training and experience, demonstrated abilities, and current competence, not on specialty designation alone. This general policy should certainly apply to ordering and interpreting office diagnostic imaging. As indicated above, many AAFP members offer radiology services in their practices.

Patient convenience and satisfaction are improved by the presence of on-site radiography. Traveling to another facility places an additional burden on patients and caretakers, especially for the elderly and the disabled, delaying appropriate diagnosis and treatment, especially with late afternoon or Friday appointments. This may be one source of the finding, mentioned above, that general practitioners in New Zealand reported an increase in ED referrals and hospital admissions in areas of decreased patient access to imaging services.15 Patient care will be compromised if radiographs are required for appropriate evaluation and treatment, but circumstances prohibit travel or the patient refuses to go to another facility.

The Centers for Medicare and Medicaid Services (CMS) policy for Medicare Part B payment for the professional component of diagnostic radiography does not discriminate on the basis of specialty where payment is concerned. Chapter 13, Section 20.1 of the Medicare Claims Processing Manual states, “Carriers must pay for the PC [professional component] of radiology services furnished by a physician to an individual patient in all settings under the fee schedule for physician services regardless of the specialty of the physician who performs the service.”17

In a related policy regarding interpretations of in the ED, CMS states that carriers will pay for radiology services if the following requirements are met:

"The services are personally furnished for an individual beneficiary by a physician.

The services contribute directly to the diagnosis or treatment of an individual beneficiary.

The services ordinarily require performance by a physician.

And the services are identifiable, direct, and discrete diagnostic or therapeutic services furnished to an individual beneficiary, such as interpretation of x-ray plates, angiograms, myelograms, pyelograms, or ultrasound procedures. Payment for a professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary’s medical record maintained by the hospital.”17 In addition, CMS policy also states, “Generally, payment is made for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient.” When multiple claims for the same interpretation occur, “Payment is made for the interpretation and report that directly contributed to the diagnosis and treatment for the individual patient. We will consider the second interpretation to be a quality control service. The physician specialty is not the primary factor in deciding which interpretation and report to pay regardless when the service was performed.”18

The American Medical Association (AMA) approved policy D-385.974, Freedom of Practice in Medical Imaging, in 2010:

Our AMA will:

encourage and support collaborative specialty development and review of any appropriateness criteria, practice guidelines, technical standards, and accreditation programs, particularly as Congress, federal agencies, and third-party payers consider their use as a condition of payment, and to use the AMA Code of Ethics as the guiding code of ethics in the development of such policy;

actively oppose efforts by private payers, hospitals, Congress, state legislatures, and the Administration to impose policies designed to control utilization and costs of medical services unless those policies can be proven to achieve cost savings and improve quality while not curtailing appropriate growth and without compromising patient access or quality of care;

actively oppose efforts to require patients to receive imaging services at imaging centers that are mandated to require specific medical specialty supervision and support patients receiving imaging services at facilities where appropriately trained medical specialists can perform and interpret imaging services regardless of medical specialty; and

actively oppose any attempts by federal and state legislators, regulatory bodies, hospitals, private and government payers, and others to restrict reimbursement for imaging procedures based on physician specialty, and continue to support the reimbursement of imaging procedures being performed and interpreted by physicians based on the proper indications for the procedure and the qualifications and training of the imaging specialists in that specific imaging technique regardless of their medical specialty.19

According to the American Academy of Orthopaedic Surgeons (AAOS), “The AAOS believes that orthopaedists are entitled to adequate compensation for the cost and work involved in providing [musculoskeletal radiographic studies] in their offices. Any policy which prohibits orthopaedists from performing and interpreting diagnostic imaging studies in their offices interferes with the patient’s ability to receive optimal care.”20

In June 2006, the American College of Emergency Physicians reaffirmed a policy statement that endorses the principle that, “The emergency physician providing contemporaneous interpretation of a diagnostic study is entitled to reimbursement for such interpretation even if the study is reviewed subsequently as part of the quality control process of the institution in which the physician practices.”21

According to the AAFP 2009 Practice Profile Survey, 46.3 percent of family physicians are estimated to have radiography equipment in their offices.3 Patient care is improved when the family physician is able to fully integrate the patient’s history and physical examination with contemporaneous interpretation of diagnostic imaging and other diagnostic studies. Family physicians, like other physicians who use diagnostic radiography in their evaluation of patients, are entitled to appropriate compensation for their services.

Section II: Clinical Indications

Many clinical conditions that present in a family physician’s office, including acute trauma, acute illness, chronic musculoskeletal pain, and chronic illnesses, require diagnostic radiography as part of the evaluation. Well-accepted criteria for diagnostic radiography are reported in the literature for acute knee and ankle injuries that are commonly evaluated and treated in the family physician’s office.22-26 Recommendations for indications for office radiographs from a family physician’s perspective have been published.26 Patient perception of necessity of imaging may influence the frequency of radiographs,27 and nonclinical indications, such as patient reassurance or work-related injury, have also been reported in some studies.28,29

Efforts to limit types of radiologic studies that may be performed by nonradiologists, either by imposing guidelines or by restricting payment, have been reported, but they have had limited initial impact on total costs.30,31 These studies did not include sufficient analysis to address the impact on different physician specialties.

The ACR Committee on Appropriateness Criteria and its expert panels use literature review and a modified Delphi technique to develop clinical practice guidelines based on clinical indications for a large number of diagnostic imaging and therapeutic techniques.32,33 Representatives from fifteen nonradiology specialty organizations participate in the process, but it appears that no family physicians are presently participating in the development of the ACR Appropriateness Criteria®32 The criteria address a large variety of clinical conditions, and each topic includes recommendations and a summary of the relevant literature. Many indications for plain radiographs are acute and chronic conditions that frequently present in the family physician’s office.

Initial radiologic evaluation of a large variety of acute and chronic conditions is appropriately performed in the family physician’s office, with referral to another facility for more extensive imaging, if necessary.

Section III: Training Methodology

Training in diagnostic imaging interpretation begins during clinical training in medical school, although the amount and intensity of the training experience at various medical schools can vary widely.

The Residency Review Committee accredits family medicine residency programs and has developed a set of requirements that became effective July 1, 2007.34 The Diagnostic Imaging and Nuclear Medicine requirement states, “The program must provide the residents with a structured opportunity to learn the appropriate application of techniques and specialty consultations in the diagnostic imaging and nuclear medicine therapy of organs and body systems. Instruction should include the limitations and risks attendant to these techniques. The format of the instruction should be adapted to the resources available, but must include radiographic film/diagnostic imaging interpretation and nuclear medicine therapy pertinent to family medicine.”

Extensive individualized training also occurs during acute and chronic patient care in the hospital, ED and continuity practice experience during residency training. This training occurs during consultation with family physician and emergency medicine preceptors, and during formal and informal consultation with interpreting radiologists. Additional training occurs when residents’ provisional readings that result in patient-care decisions are reinforced or adjusted based on the written radiologists’ reports.

For family physicians who use diagnostic radiography in their practices, training and feedback continue through consultation with practice colleagues and radiologists throughout the family physician’s career.

Section IV: Testing, Demonstrated Proficiency and Documentation

An appropriate level of competence for ordering and interpreting diagnostic radiographs, as judged by the supervising faculty, is expected for residents to advance through their training. Deficiencies would be addressed by more intense remedial training, as with any other educational category for family medicine.

Testing of knowledge of indications for and interpretation of diagnostic radiographs is a part of the general testing for certification by the American Board of Family Medicine. Certification examinations include questions about diagnostic radiography and some radiographic images. Radiography is considered one of many general areas of medical knowledge tested, and there are no specific rules for numbers of interpretations of radiographs or questions about radiography on each primary certification or recertification examination.35

Section V: Credentialing and Privileges

The issue of hospital privileges is not relevant to outpatient radiograph interpretation. However, it is becoming more common for managed care and health insurance organizations to request that participating physicians go through a credentialing process, either to meet internal standards or as a part of an application for National Committee for Quality Assurance (NCQA) accreditation.36 The NCQA credentialing is based on licensure, Drug Enforcement Agency certification, education and training, malpractice claims history, medical board sanctions and Medicare/Medicaid sanctions, ongoing monitoring of sanctions, and work history.37 Specific procedures or skills are not usually considered in the credentialing process.

The Joint Commission’s ambulatory standards include general guidelines about equipment safety and maintenance, and clinician training and credentialing for services they provide, but no specific standards related to use of office radiography or interpretation of radiographs.38

Verrilli reported a program by BlueCross BlueShield of Massachusetts for technical and professional privileging.31 Technical privileging was based on radiography equipment and processes meeting appropriate standards of care. Professional privileging was based on a list of “appropriate” physicians’ Current Procedural Terminology (CPT-4) codes for each specialty, specialty society recognition that imaging is an integral part of their practice, and physician training for conducting and interpreting the imaging test.

Centers for Medicare and Medicaid Services may have an impact on credentialing as it relates to Medicare billing. In its March 2005 Report to Congress, “Medicare Payment Policy,” the Medicare Payment Advisory Commission (MedPAC) recommended that Congress direct the Secretary of Health and Human Services to set standards for physicians who bill Medicare for performing and interpreting diagnostic imaging studies. MedPAC specifically recommended that, “Medicare should not limit payment to specific specialties” and that “standards should be based on some combination of physician training, experience, and continuing education.”1

To date, there have been limited efforts to restrict performing and interpreting outpatient radiographs by family physicians through a credentialing process, but this may change if new standards are developed by CMS for Medicare billing.

Section VI: Miscellaneous Issues

A. Competence for interpretation of diagnostic radiographs

Several studies have evaluated the frequency of agreement between a primary care physician’s reading of office radiographs and the radiologist’s reading. Concordance between readings by family physicians and radiologists was found in 72.5 to 92.4 percent of all radiographs.39-42 In addition, concordance between readings by internists and radiologists was found in 92 percent of all radiographs.43 Concordance for extremity films was higher, from 79 to 96 percent.38,40-42 Concordance rates were lower for chest radiographs, ranging from 41.9 to 89.5 percent,38-45 probably reflecting a greater level of complexity. Different criteria for concordance were used, so results from different studies are not directly comparable.

Similar studies of primary care physicians’ and emergency physicians’ readings of radiographs obtained in EDs yielded concordance rates of 83.2 to 99.3 percent.46-55 As with the primary care office radiograph reading studies above, different criteria for concordance were used, so results are not directly comparable.

Studies of discordance between radiologists for readings of chest x-rays have shown disagreements for 18 to 57 percent of readings.56-61 Disagreements between radiologists for a variety of radiographs have been reported to occur between 3 and 4.4 percent of readings.62-64 Franken and colleagues found that 35 percent of discordant readings were ultimately determined to have been correctly interpreted by the family physician.45

Primary care clinicians may have an advantage in interpreting radiographs accurately in that they are likely to have a more complete clinical history for the patient than a radiologist. A recent review by Loy reported that the majority of studies showed higher accuracy of radiograph readings when clinical information was provided, while a few studies showed no effect, and none showed a decrease in accuracy.65

The literature suggests that although family physicians are not perfect in their interpretations of diagnostic radiographs, their error rates are similar to the rates experienced by radiologists.

B. Necessity of a second radiograph reading

A variety of studies have been published in recent years addressing the issue of whether a second reading by a radiologist improves clinical care. Family physicians refer patients for specialty consultation for numerous reasons and are usually able to determine when such consultation is needed. The Halvorsen and Smith surveys found that 73 percent66 and 82 percent67 of the physician respondents thought that family physicians should be able to select which radiographs should be reread by a radiologist. Review of the literature does not support mandatory rereading of all radiographs taken in family physicians’ offices.

In 2004 Smith reported a study of 1,393 pairs of radiograph readings from 86 primary care clinicians in 9 ambulatory practices and 42 radiologists in Wisconsin. In a subgroup of 553 pairs – instances where the clinicians said they would not have requested a second reading if it hadn’t been required – researchers found that for only 2.5 percent of patients would clinical care have been any different without the second reading. Moreover, they found “zero substantial changes in care or episodes of averted patient harm.”40 Similarly Halvorsen reported only 4 of 508 radiographs with clinically significant discordance and zero substantial changes in care.44

Several studies of radiography readings in EDs have addressed the issue of changes in care that result from the radiologists’ second reading. Lufkin reported a change in care of 11/9,599 (0.11 percent) when ED physicians were “confident” in their readings of plain radiographs.68 Two large studies reported 0.5 to 1.1 percent episodes of changes or potential changes in patient care for all radiographs that were read discordantly by the radiologist and the ED physician.52,53 Similarly, studies of orthopedists’ initial radiograph reading and clinical management with a second reading by radiologists uniformly found no change in clinical care resulting from the second reading.69-72

Addressing meaningful patient-oriented outcomes, a seven-year prospective study was conducted with 869 cancer patients randomized into a double reading group (oncologist and radiologist) and single reading group (oncologist with radiologist consultation by request) for plain radiographs taken during cancer monitoring visits. Järvenpää reported no difference in the time of detection of cancer recurrence or 5-year survival.73 Radiology second reading was not requested for 55.6 percent of the 1,927 plain radiographs in the single reading group.74

These studies suggest that a second reading by a radiologist is not always necessary and that selective request for radiology consultation is appropriate.

C. Shortage of radiologists

Several recent articles have discussed an increasing shortage of radiologists in the United States.75-77 A shortage of radiologists in the United Kingdom has resulted in the training of radiographers, called clinical specialist radiographers, to interpret and report results of radiographs done in accident and EDs. High rates of agreement with radiologists’ interpretations have been reported, and radiographers are interpreting and reporting in over 30 sites.78,79 Saketkhoo reports that 25 percent of community hospital EDs have radiology staffing shortages, and 62 percent cannot consult a radiologist about plain radiographs at night.80 A 2003 national survey of U.S. radiologists suggests that the supply and demand is fairly balanced, but there remains a shortage of radiologists in nonmetropolitan areas.81

Family physicians’ deciding which radiographs to send for radiologist consultation and second reading would free up radiologists’ time for interpretation of more complex radiographs and radiological interventions.

D. Formal relationships with other organizations

Cooperation should be encouraged between the AAFP, the ACR, the Intersocietal Accreditation Commission, and other relevant organizations in the development of quality improvement programs, radiography use guidelines, and CMS standards for office imaging.

E. Broader dissemination of ACR Appropriateness Criteria®

Broader use of the ACR Appropriateness Criteria®32,82 may have some beneficial impact by encouraging appropriate outpatient radiography use and discouraging unnecessary or inappropriate use. Studies of radiograph guideline dissemination methods have had mixed results83-87 and studies reporting a decrease in inappropriate radiographs have shown only modest improvements.85,86

F. Research agenda

The research agenda for interpretation of outpatient radiographs should focus on the following:

Quantifying whether a shift in billing for the professional component of radiology services or CMS standards for performing and interpreting outpatient radiographs would affect the financial model of the PCMH.

Defining the effect on patient-oriented clinical outcomes of the performance and interpretation of diagnostic radiographs by family physicians on-site as opposed to referral for off-site imaging and interpretation by radiologists, especially in rural and other underserved areas.

Waldrip C. American College of Radiology, Department of Quality and Safety, Program Specialist. Personal communication, November 2, 2005.

Matowe L, Ramsay CR, Grimshaw JM, Gilbert FJ, Macleod MJ, Needham G. Effects of mailed dissemination of the Royal College of Radiologists’ guidelines on general practitioner referrals for radiography: a time series analysis. Clin Radiol. 2002;57(7):575-578.

Kerry S, Oakeshott P, Dundas D, Williams J. Influence of postal distribution of the Royal College of Radiologists’ guidelines, together with feedback on radiological referral rates, on x-ray referrals from general practice: a randomized controlled trial. Fam Pract. 2000;17(1):46-52.

Oakeshott P, Kerry SM, Williams JE. Randomized controlled trial of the effect of the Royal College of Radiologists’ guidelines on general practitioners’ referrals for radiographic examination. Br J Gen Pract. 1994;44(382):197-200.

Cameron C, Naylor CD. No impact from active dissemination of the Ottawa Ankle Rules: further evidence of the need for local implementation of practice guidelines. CMAJ. 1999;160(8):1165-1168.